Longview Hill

Longview Hill Nursing and Rehabilitation Center on North Fourth Street formerly was known as Clairmont Longview.

A Longview nursing home faces a possible fine of more than $21,000 after three residents with dementia walked out of a locked unit and down Fourth Street without staff realizing they had left.

The incident occurred about 7:45 p.m. July 29 at Longview Hill Nursing and Rehabilitation Center on North Fourth Street, formerly known as Clairmont Longview.

The facility’s failure to provide enough supervision to prevent the residents from leaving its secure unit put them in “immediate jeopardy” of their health and safety, according to an Aug. 13 investigation by the Texas Health and Human Services Commission.

“The residents were found walking in the middle of the street heading away from the facility in the direction of a major intersection,” the investigator’s report said. The residents slipped away from the unit by following several visitors out the locked door without the staff’s knowledge, the report added.

When contacted by phone, Longview Hill administrator Maggie Moore declined to comment about the incident or the results of the investigation.

Two of the residents are severely cognitively impaired and considered to be at high risk for “elopement,” the Health and Human Services Commission term for leaving a long-term care facility without supervision; the third resident is in “cognitive decline” and a moderate elopement risk, the report said.

Longview Hill’s medical director was driving north on Fourth Street about 7:50 p.m. when she saw “three elderly women walking in the south bound lane headed north,” the report said. The women were about two driveways north of Longview Hill.

The medical director recognized the women, stopped and left her car to question them. They said “they were just out for a walk,” according to the report. They could state their names, but could not say where they lived. The director turned the women around, walked them back to Longview Hill and told the director of nursing and other staff what had happened.

When a Health and Human Services Commission investigator interviewed the women, “Both Resident #1 and #2 indicated they went out for a stroll on the day in question. … Resident #1 said they were cooped up all the time and they needed to blow off some steam by taking a walk. She said they did not do anything wrong,” the report said.

The Aug. 13 investigation found that Longview Hill took steps to prevent any more elopements after the incident. Codes to unlock doors to the secure unit were changed, and staff were told to keep the codes confidential and not share them with residents’ visitors or family members.

The three residents must now wear wander guards, which sound an alarm when the wearers go outside a defined area. This helps staff find and stop residents with dementia before they can leave the premises.

Longview Hill staff also underwent in-service training about wandering and elopement behaviors, door code confidentiality and identifying and preventing abuse and neglect of patients, the report said. In addition, the residents’ individual care plans and assessments of wandering behavior were updated.

The facility reported the July 29 incident to the Health and Human Services Commission within five working days, as required by federal law, commission press officer Kelli Weldon said in an email Friday.

While the commission investigator found Longview Hill in substantial compliance with state and federal regulations at the time of the Aug. 13 visit, the commission still recommended that the federal Centers for Medicare and Medicaid Services fine the facility $21,393.

“We investigated and determined there was past noncompliance and found conditions in the facility that constituted immediate jeopardy to resident health or safety,” Weldon said, referring to the July 29 incident.

“The recommendation is preliminary. The facility will have an opportunity to appeal, and the final decision to assess the penalty rests with CMS,” she wrote in her email.

Weldon urges anyone with concerns about the health and safety or quality of care provided to residents of any long-term-care facility to call the HHSC complaint hotline at 1 (800) 458-9858. Callers can remain anonymous.

In an emergency or life-threatening situation, call 911 or local law enforcement, she said.